Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Requested a Senior Discount after I processed the payment 2/28/19 KS$14 Refund Pending. 3/1/19 BHRefunded. 3/3/19 BH |
| Membership Type | Individual Plan ($99.95) |
| Are you renewing your plan? | Yes |
| Please enter your current membership ID# here. You can find this in your renewal email or on your current membership card. | 1755893842 |
| Your Name | Irene Acri |
| Phone | (412) 793-1741 |
| Date of Birth | 06/09/1937 |
| Referred by or Referral Code | ExMail 09/29/26 |
| Enter Office Code | A14978 |
| Address | 5785 Saltsburg Rd Apt 301 Verona, PA 15147 Map It |
| Payment Method | Check |
| Payment Received | Paid |
| Total | $99.95 |
| Go Green | Paperless Option | not |
| Terms |  I have read the Terms and Conditions and wish to purchase the Discount Medical Plan. |
| Plan Information | |
| Newest Membership: Programmatically pick Plan Start Date Based on either new plan or their ID number here | 11/15/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/15/2027 |
| Membership ID Number | 1790697993 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 8 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
